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SAN JOAQUIN COUNTY ENVIRONMENTAL HEALTH DEPARTMENT <br /> SERVICE REQUEST <br /> Type of Business or Property FACILITY ID# SERVICE REQUEST# <br /> RaAAkL QEf/OE.Vr141— 11P4SrZeAa � 3 <br /> OWNER I OPERATOR <br /> CHECK It BILLING ADDRESS <br /> RO ,F /r14z qNE Fi20ST <br /> FACILITY NAME <br /> SITE ADDRESS ,� LQj�E TjC'EE 49,4,4CV AA+L.F-7953�w <br /> 303 Street Number Direction Street Name city Zip Code <br /> HOME Or MAILING ADDRESS (if Different from Site Address) <br /> Street Number Street Name <br /> CITY STATE ZIP <br /> PHONE#1 Ezr. APN# LAND USE APPLICATION# <br /> PHONE#Z Ex-r. BOS DISTRICT LOCATION CODE <br /> ( ) <br /> CONTRACTOR/ SERVICE REQUESTOR <br /> REQUESTOR CHECK if BILLING ADDRESS <br /> 4,061 Ckb, /VE <br /> BUSINESS NAME PHONE# Exr' <br /> CL)�FSN fu ( -/ 03 <br /> HOME or MAILING ADDRESS FAx# <br /> o. 3 ( ) �e-zs98 <br /> CITY L STATE CA <br /> ZIP {3 Q/ <br /> BILLING ACKNOWLEDGEMENT: I, the undersigned property or business owner, operator or authorized agent of same, <br /> acknowledge that all site and/or project specific ENVIRONMENTAL HEALTH DEPARTMENT hourly charges associated with this project or <br /> activity will be billed to me or my business as identified on this form. <br /> I also certify that I have prepared this app . ation and that the work to be performed will be done in accordance with all SAN JOAQUIN <br /> COUNTY Ordinance Codes,Standards, and VJL <br /> APPLICANT'S SIGNATURE: DATE: <br /> PROPERTY/BUSINESS OWN ER OPERATOR/ ER ❑ ER AUTHORIZED AGENT OK <br /> If APPLICANT is not the BILLING PARTY proof of art Orization to Sign is required Title <br /> AUTHORIZATION TO RELEASE INFORMATION: When applicable, I, the owner or operator of the property located at the <br /> above site address, hereby authorize the release of any and all results, geotechnical data and/or envirocirrrentallsite assessment <br /> information to the SAN JOAQUIN COUNTY ENviRONMENTAL HEALTH DEPARTMENT as soon as it is available and at the same time it is <br /> provided to me or my representative. <br /> TYPE OF SERVICE REQUESTED: PFDITED SO/L SG(/7 B/L/ Tl{D ENT <br /> COMMENTS: - <br /> ���`o I��� t/ ' uta 3 0 2005 <br /> SAN JOAQUIN COUNTY <br /> D�, J ENVIRONMENTAL <br /> 1, q HEALTH DEPARTMENT <br /> ACCEPTED BY: EMPLOYEE#: 3t> DATE: �7 D <br /> ASSIGNED TO: EMPLOYEE#: a lx} DATE: (2 J Q <br /> Date Service Completed (if already completed): SERVICE CODE: 7,2, PIE: p� <br /> Fee Amount: 3 Z ..- Amount Paid Payment Date 0 S <br /> Payment Type . Invoice# Check# 'a .0 Received By: 16 (S" <br /> EHD 48-02-025 SR FORM(Golden Rod) <br /> REVISED 11/17/2003 <br />